The health bill amendments toughen up the requirements for GP commissioners to work with secondary care and local authorities and place some restrictions on procurement. Three commissioning pioneers explain how they are ahead of the curve.
Competition and tendering
The Government has introduced safeguards on competition including measures to allow any qualified provider (AQP) to be used only where there is a national or local tariff to avoid price competition. However, last month the Department of Health issued operational guidance saying PCT clusters must identify three or more community or mental health services in which to implement patient choice of AQP in 2012/13.
‘Procurement is very much about horses for courses'
Deborah Evans, chief executive of NHS Bristol, has organised a whole set of services into a framework for AQP for the next three years including dermatology, ENT, elective assessments, general surgery, oral surgery, gynaecology, pain management and tier 1 weight management.
She said: ‘I think the bill restricts AQP to services on the national tariff because it is a safe thing to do. It has to work where there is a national published price for the service.
I think the idea of this amendment is that they are trying to clarify for the public and professionals that the intention is not for providers to compete on price.
‘But I think procurement is very much a question of horses for courses. AQP is good for encouraging choice. But we're using a whole range of other methods where AQP wouldn't be appropriate.
‘We recently had a look at local community child health services. This was provided by two acute trusts, a mental health trust and two PCTs, and we wanted a single provider and to look at a different model. We spent about six months on a very inclusive "competitive dialogue" process, involving all the professionals in the field, families and social care, and held workshops where we tried to envisage the best community child health services we could.
‘We then advertised very widely – including in the European Journal – and let all our contacts know that we were looking for providers. Some 20-odd organisations were initially interested.
‘Next, we sat down and worked out the outcomes we were after – a kind of speed dating. We put all the interested organisations in a room together, and when you do that partners emerge. What we ended up with was a partnership between North Bristol Trust and charity Barnardos.
‘In the process of deciding who was best placed, we used a lot of different assessors and drew from a wide variety of sources, including GP leaders, national experts and service users. In term of costing, first we had to do a huge amount of work to separate out the finances of the five original providers and work out how much we were spending – and therefore, how much we wanted to spend on the new service.
‘Another example is home chemotherapy. I met a service user who'd gone privately for chemotherapy after breast cancer. As part of the private package, you get chemotherapy at home, which NHS providers don't do. So in order to provide this, we created a partnership between University Hospitals Bristol Foundation Trust and Staffordshire-based private company Healthcare at Home.
‘It was an intensive process. With the help of oncologists, we worked out which treatments were suitable for doing in the home and worked up a menu for breast cancer, lung cancer and so on.
‘It was rolled out over a financial year, during which we treated about 200 people. Now it's part of the standard offer. It's been evaluated by Cardiff University, which looked at carbon footprint among other things, and it has evaluated very well.
‘A third example is patient transport. Locally, transport for patients to outpatient appointments and so on needed a complete root-and-branch review. We wanted a complete service specification, and we wanted a green specification to include how to drive in the most efficient way.
‘There were difficulties around how to accommodate cancelling, rebooking and punctuality. We wanted to improve the patient experience.
‘We got interest both from inside the NHS and from logistics companies. What we ended up with was the Great Western Ambulance Service, which originally provided the service, but on a completely transformed specification – we basically got a much better service out of them.
‘And rather than letting the service in one block, we let a smaller "lot" separately – the service-to-satellite renal dialysis units. The benefit of splitting things into smaller lots is that you can get smaller businesses to compete for these. We ended up with a consortium of taxi companies that couldn't have taken on the whole contract, but they could do this bit, worth about £600,000.'
Health and Wellbeing Boards
Health and wellbeing boards are being given a beefed-up role as part of the Government's drive to increase accountability in the reformed NHS.
The DH says health and wellbeing boards will have a stronger role in local commissioning, with the right to refer back local commissioning plans that are not in line with the health and wellbeing strategy.
‘Health and wellbeing boards will prevent problems being passed between organisations'
Dr Joe McGilligan, chair of EsyDoc and a GP in Redhill, Surrey, says: ‘I'm the clinical co-chair of our health and wellbeing board, along with Michael Gosling – the co-chair from the council. The board was set up in May this year when all the clinical commissioning group (CCG) chairs were invited to attend.
‘Michael – a cabinet member for adult social care and health at Surrey County Council – chaired the first meeting, but asked for a clinician to stand as co-chair. I took soundings from others and asked if I was thought a suitable candidate. The chair thought I was and appointed me co-chair.
‘The board consists of all the CCG leads – though in practice I suspect most will nominate a lead to represent them rather than every lead attending.
‘Its main job is set out in the 2010 health white paper, Equity and Excellence, Liberating the NHS – joining up commissioning of local NHS services, and bringing social and health improvement. It's real task will be to promote good collaborative working between all the parties and ensure the joint strategic needs assessment is used and applied to all the commissioning intentions and resource allocations.
‘The board is currently in shadow form, and with the bolstering of its role and responsibilities set out in the amendments to the health bill, I see it as the forum to ensure that health and social care is delivered to the best ability within the resources available and prevent problems from being passed between organisations.
‘Every organisation feels their budgets are wrong and struggles to achieve their goals, but by airing and sharing the board will break down organisational boundaries.
‘Nationally, CCGs will take advice from clinical senates to help develop their plans, but will not be dictated by them. This is because it may not be what their local population needs if you take in all the other factors such as deprivation or the use of the independent sector.
‘I think the tensions between health and politics will be broken down because we will both finally understand where each is coming from and the demands on each others' resources. There will be much more sharing of the whole of social care problems including housing, schools and health.
‘Having public health take on a bigger role is crucial because they can take the whole population approach and then interpret it locally – creating plans devised to help solve those issues, which will take longer than the annual budget-balancing exercise that happens presently.
‘Understanding that there has to be investment in whole health promotion now will result in better outcomes. There has to be a whole-system approach, with each party bringing its expertise to the table, sharing it and coming to a system response.'
Closer working with consultants
In its Future Forum response, the Government said CCGs must have at least one secondary care specialist on their governing body – but to avoid conflict of interest, they could not work for a local provider. Clinical senates, consisting of doctors, nurses and other health professionals who may work for local providers, have also been announced, designed to be a source of expert support.
‘The boundary between primary and secondary care is entirely artificial'
Baywide GP Commissioning Consortia (GPCC) represents all 21 GP practices in the Torbay, Devon, area. It has a board of 10 directors – eight GPs, one practice manager and one nurse practitioner – plus several co-opted members including the director of public health, a community nurse, a patient representative, a community pharmacist and the director of operations from the PCT.
In the past year, it has also reshaped its 20 clinical groups that look at specific specialties to give both primary and secondary care an equal voice.
Dr Sam Barrell, chair of Baywide GPCC, said: ‘I think what distinguishes us from other commissioning groups is our relationship with secondary care, with consultants and nurses. We really do have a strong partnership already. We had reasonable relationships before, but in the past year it has accelerated 10-fold.
‘We realise that we have to work together and we have worked extremely hard on it. We've had two huge training events for everyone involved and reshaped our clinical commissioning groups – 20 committees working on specialties such as cardiology and ENT – which give both primary and secondary care a voice.
‘These clinical commissioning groups – not to be confused with the new name for GP consortia – used to have huge membership with up to 20 members each, but now they've completely changed. Membership is now less than 10 each and there are waiting lists among GPs to join them. We have a clinical engagement budget so we can pay GPs for locum cover and they all have performance dashboards for data, and look at care pathways – quite a lot is now mapped out on our local version of the Map of Medicine.
‘As part of that, we've got ongoing talks on bringing more service into the community through projects such as a community dermatology service.
‘On the 20 clinical commissioning groups, there are roughly equal numbers of consultants and GPs, usually two of each plus allied health professionals – a respiratory nurse, for example – a commissioning manager and perhaps an operations manager from the provider organisation. The consultants bring specialist knowledge of that area – what leading-edge things would be good to bring into the mix. The angle of the GP is: will that fit with the overall commissioning priorities? It's all about the balance of spend.
‘The problem in the past before these groups were reshaped was they tended to be very secondary care focused. GPs were invited along, but in a tokenistic way. Now the GPs have a much greater say.
‘We're not threatened by the thought of nurse or consultant input. The rationale is good: you need to clinically look at the whole system together. We have a nurse practitioner on our board, a community nurse co-opted. We have invited our (hospital) medical director to sit on our commissioning board which seems logical.
‘I do wonder about the logic of having someone from outside the area, however. I suppose they'll be there because of the potential conflict of interest of having someone local from the provider perspective. But the conflict of interest could still be there with someone from up the road, who might think their provision is better and suggest moving patients there.
‘In reality, we've all got conflicts of interest – GPs are small businesses after all. But with the right governance in place it shouldn't be a factor. We'd much prefer to work with a local consultant. We need them on board, not somebody from somewhere else. It starts to be a bit tokenistic when it would actually be really useful to have someone from the area involved.
‘In practice, it won't be a problem logistically for us. We could swap medical directors with the Royal Devon and Exeter (Foundation Trust). But whether they would want to attend is another matter.
‘Success in three years' time would be new services in the community that are higher quality and more responsive to patients' needs. Wider success would be to achieve clinical integration across the whole of the care pathway.
‘The boundary between primary and secondary care is entirely artificial and if clinicians can work together wherever is best for the patient along the care pathway, we will see true success by removal of duplication, improved communication and data sharing and a seamless journey for the patient.'